A Brief Overview A Brief Overview ofof

Trichotillomania Trichotillomania Trick- oh – till – oh – main – ee- ahTrick- oh – till – oh – main – ee- ah

compulsive hair pullingcompulsive hair pulling

Scalp Pulling DamageScalp Pulling Damage

Lash and Brow Pulling DamageLash and Brow Pulling Damage

Who Gets Trichotillomania?

PrevalencePrevalenceHair PullingHair Pulling

• DSM-III-R TTM prevalence estimates of 0.6 - 3.4%

Christenson GA, Pyle RL, Mitchell JE. Estimated Lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52:415-417

• 10% prevalence estimates of “non-clinical hair pulling” in student populations when criteria are relaxed. (B & C are dropped.) Stanley MA, Borden JW, Bell GE, & Wagner GE. Non-Clinical Hair Pulling: Phenomenology and Related Psychopathology. 1994; 8:119-130

A. Recurrent hairpulling with noticeable hair loss

B. Tension before pulling or when attempting to resist

C. Pleasure, gratification, or relief when pulling

D. Not better accounted for by another disorder and not due to a general medical condition

E. Clinically significant distress/functional impairment

DSM IV-R Definition of DSM IV-R Definition of Trichotillomania (TTM)Trichotillomania (TTM)

How Should it be Classified?How Should it be Classified?

• It is NOT Obsessive Compulsive Disorder (OCD)!

• Is it an OC-Spectrum Disorder?

• A Stereotypy Disorder?

• A Body Focused Repetitive Behavior? (BFRB)

• How SHOULD it be classified?

• DSM-V Workgroup is pondering this very question

The DSM and Current ICD Classification: The DSM and Current ICD Classification:

Impulse Control DisordersImpulse Control Disorders

• Intermittent Explosive Disorder • Kleptomania • Pyromania • Pathological Gambling • Trichotillomania

Impulse-Control Disorders Impulse-Control Disorders Not Otherwise SpecifiedNot Otherwise Specified

ICD-NOSICD-NOS

This category is for disorders involving impulsive behaviors not mentioned in the main category. For example, compulsive sexual behavior, compulsive shopping, or skin picking, to the extent that this behavior damages the person's relationships and causes significant distress and trouble to the person.

Recommended Classification:Recommended Classification:Body Focused Repetitive BehaviorsBody Focused Repetitive Behaviors

• Compulsive Hair Pulling (TTM)• Compulsive Skin Picking (CSP)• Excessive Nail Biting (Onychophagia)• Excessive Nose Picking• Excessive Lip Picking• Excessive Cheek biting

• Common traits:repetitive, self-soothing, body-focused, grooming / pseudo-grooming related

The Trichotillomania Impact Project:The Trichotillomania Impact Project:Exploring Phenomenology,Exploring Phenomenology,

Functional Impairment, Functional Impairment, & Treatment Utilization& Treatment Utilization

Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin R, Stein DJ, Walther M,

& The TLC Scientific Advisory Board

Published December 2006: Journal of Clinical Psychiatry

• Scalp 79%

• Eyebrows 65%

• Eyelashes 59%

• Pubic 59%

• Legs 30%

• Arm 17%

• Other 25%

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Most Common Pulling SitesMost Common Pulling SitesAdultsAdults

• Scalp 85%

• Eyebrows 52%

• Eyelashes 38%

• Pubic 27%

• Legs 18%

• Arm 9%

• More than one 58%

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Most Common Pulling SitesMost Common Pulling SitesChildrenChildren

Characteristic Response

• Unpleasant urges prior to pulling 71-89% of time

• Pull to achieve a certain bodily sensation 30-70% of time

• Pulling preceded by bodily sensation 71-89% of time

• Pulling preceded by physical and mental anxiety 0-10% of time

• Urge increases when resisting 71-89% of time

• Post pulling anxiety 90-100% of time

• Awareness of pulling 71-89% of time

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Pulling Characteristics - Pulling Characteristics - AdultAdult

• Pulling severity similar to Adult TTM

• 29% never/almost never experienced tension prior to pulling

• 13% never/almost never experienced “pleasure, gratification, or relief” after pulling

• 4% said they were “Never” or “Almost Never” aware of pulling

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Pulling PhenomenologyPulling PhenomenologyChildrenChildren

Trichobezoars: Hair Balls• Approximately ¼ of the TTM population does

something oral with the hair – from rubbing it on a lip to ingesting part or all of the hair: causing the potential for a trichobezoar, or “hair ball” to develop because hair is not digestible. If a trichobezoar does form, it can become life threatening and must be removed surgically.

Other Medical ProblemsOther Medical Problems

• Other complications can arise as a result of pulling and picking behavior, such as:

• Neuromuscular Problems• Carpal Tunnel Syndrome• Infections• Avoidance of Medical Care

Anxiety and BFRBsAnxiety and BFRBs

34

36

38

40

42

44

46

STAI

Sco

res

No-BFRB BFRB

On average, adults with a BFRB were more anxious than persons without a BFRB

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Depression and BFRBsDepression and BFRBs

On average, adults with a BFRB were more depressed than persons without a BFRB

02468

10121416

BDI S

core

s

No BFRB BFRB

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Occupational:

• 23% report daily interference w/ job duties • 15% reported failing to pursue job advancement• 4% reported having quit a job b/c of pulling

Academic:

• 76% report difficulty w/ studying b/c of pulling• 5% reported having dropped out b/c of pulling• Mean of 9 missed school days/yr. due to pulling

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Occupational/Academic Impact

Functional Impairment in Children

• 55.6% of parents reported their children avoided social or recreational activities.

• 54.9% of children reported TTM interfered with studying.

• 36.1% of children reported TTM impaired academic performance.

The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & The Trichotillomania Impact Project: Exploring Phenomenology, Functional Impairment, & Treatment Utilization Treatment Utilization J Clin Psychiatry 67:12, December 2006J Clin Psychiatry 67:12, December 2006

Recommended Treatment

Challenges in TreatmentChallenges in Treatment

• Limited Public and Professional Awareness

• Sufferers fail to initiate treatment due to limited awareness

• Many mental health providers still diagnose it as OCD and minimize its severity/impact

• Lack of trained professionals often results in poor treatment outcomes

Cognitive-Behavioral Model

• Behavior is a function of: antecedents and consequences

• Antecedents: (things before…)– Visual, kinesthetic, tactile, affective, cognitive,

environmental

• Consequences: (things after…)– Positive emotional state, tension reduction,

pleasurable sensation

Behavioral TreatmentBehavioral Treatment

• Cognitive Behavioral Treatment

– Habit Reversal Training– Stimulus Control – Comprehensive Behavioral Approach (ComB)

– Acceptance and Commitment Therapy– Dialectical Behavior Therapy

PharmacotherapyPharmacotherapy • The literature includes case reports, a few case series,

open trials and a few control studies. • No drug has received FDA approval for TTM.• Results across studies have been contradictory with

only some showing modest improvement on meds.

• Medications Used in the Treatment of TTMSelective Serotonin Reuptake InhibitorsOther AntidepressantsOpiate AntagonistsMood StabilizersAnxiolyticsNeurolepticsTopical Agents Other Agents (ie, Methylphenidate)

Non-PrescriptionNon-Prescription

• Inositol (B-vitamin family) • N-acetyl-cysteine “NAC” (amino acid) • NAC - Recent Double Blind Study completed with

promising results.

• DietSugarCaffeineFood AllergiesMissing Nutrients - i.e. DHA

Other Other Non-Pharmacological Non-Pharmacological

ApproachesApproaches• Psychotherapy• Hypnotherapy• Support groups • Meditation• Prayer• Diet / Exercise• Stoppulling.com / Stoppicking.com

Current research Overview:TLC’s Role in Promoting…

More research has taken place in the last two decades on TTM than in the previous 100 years.

This dates from the inception of the Trichotillomania Learning Center.

TLC Funded ResearchTLC Funded Research 8 Pilot Studies have been funded by the TLC Research Fund8 Pilot Studies have been funded by the TLC Research Fund

2003 2003 Investigating the Efficacy of Combined Habit Reversal and Acceptance and Investigating the Efficacy of Combined Habit Reversal and Acceptance and Commitment Therapies as a treatment for TTMCommitment Therapies as a treatment for TTM

2003 2003 A Comparison of Phenomenological Factors in TTM and TS (Tourette’s A Comparison of Phenomenological Factors in TTM and TS (Tourette’s Syndrome)Syndrome)

20042004 TTM: Investigating Clinical & Genetic Variants in the Genetically Homogeneous TTM: Investigating Clinical & Genetic Variants in the Genetically Homogeneous Afrikaner PopulationAfrikaner Population

20052005 Investigating the Efficacy of Combined Habit Reversal and Acceptance and Investigating the Efficacy of Combined Habit Reversal and Acceptance and Commitment Therapies as a treatment for Chronic Skin PickingCommitment Therapies as a treatment for Chronic Skin Picking

20082008 Two Icelandic Research Studies on Pathological Skin PickingTwo Icelandic Research Studies on Pathological Skin Picking

20082008 The Comprehensive Survey on Trichotillomania: Analysis of a Large Data Set The Comprehensive Survey on Trichotillomania: Analysis of a Large Data Set from 1,154 Hair Pullers from 1,154 Hair Pullers

20082008 Proposed Functional fMRI Study in TTM (neuroimaging)Proposed Functional fMRI Study in TTM (neuroimaging)

20092009 Double-Blind, Placebo-ControlledT rial of N-acetylcysteine for Childhood TTM Double-Blind, Placebo-ControlledT rial of N-acetylcysteine for Childhood TTM

Pediatric Manual NIMH grant 2003Pediatric Manual NIMH grant 2003 NIMH RO1 Grant – Pediatrics 2008NIMH RO1 Grant – Pediatrics 2008 NIMH RO1 Grant – Adult 2008NIMH RO1 Grant – Adult 2008

Impact Validation / Genetics ProjectImpact Validation / Genetics Project MGH Family Nature/Nurture Study MGH Family Nature/Nurture Study

Addiction modeling studies Addiction modeling studies (needed)(needed)Medication studies Medication studies (needed)(needed)

Larger Research ProjectsAssisted by TLC

Why are Genetics Important?

• To identify rational treatment, understanding the underlying biological processes that create the pathology (illness) allows the development of effective intervention at an appropriate point.

• Several genes have now been implicated in some cases of TTM. (Research is still in early stages.)

• These genes are Hoxb8, SLITRIK1, and SAPAP3

Barbering in Mice: an Animal Model?

• ““Barbering” (fur and whisker trimming in laboratory Barbering” (fur and whisker trimming in laboratory mice) can be a spontaneous animal model for TTMmice) can be a spontaneous animal model for TTM

• Similarities to TTM: Barbering mice pluck focused Similarities to TTM: Barbering mice pluck focused areas of hair, a female bias exists, onset is normally areas of hair, a female bias exists, onset is normally during puberty, and post-pulling tactile and oral during puberty, and post-pulling tactile and oral behaviors are noted.behaviors are noted.

Usually one unmarked barberUsually one unmarked barber

Barber is usually dominantBarber is usually dominant

Morphometric Neuroimaging Findings

• Decreased size of the left putamen in TTM vs control subjects

• Decreased size of cerebellar cortex in TTM vs control subjects

• TTM severity scores were inversely correlated with L primary sensorimotor cerebellar cluster volumes, with smaller volumes associated with more severe TTM.

SRT in TTM (Serial ReactionTime)

The SRT is a neuroimaging test given to subjects while their brains are being scanned. It involves measuring reaction times in response to signals given.

• No activation in either the striatum or hippocampus evident with the SRT in TTM

• This suggests different brain circuitry involved in TTM and OCD

Current and Future Research

• TLC has begun to establish a data repository for both phenotypic and genetic materials.

• One goal is to learn more about TTM.Symptoms / Course / Outcome

• Another goal is to find genes that increase the risk for TTM.

• Eventually, this information should lead to better treatments for people who suffer from this disorder.

Summary of Recent Research Summary of Recent Research & Advances in Treatment& Advances in Treatment

• TLC-sponsored research has led to significant advances in the understanding of both child and adult TTM over the past few years

• These scientific gains have led to significant advances in treatment (primarily cognitive-behavioral treatments)

• Combined intervention addressing multiple aspects of TTM may be the most effective approach

• Ongoing work in behavioral, genetic, animal, and neuroscientific aspects of TTM should lead to more effective treatments over the next few years

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